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Based on the tour of the facility and staff verification, the facility failed to remove expired items from patient care areas. This has the potential to affect all patients receiving care in the facility. The facility's active census at the time of the survey was 8 patients.

Findings include:

Tour of the emergency department completed on 09/16/13 at 2:30 PM, revealed expired sterile packs within an equipment storage cart in room 8. The sterile packs had expiration dates of July 7, 2012, September 2, 2012, August 1, 2013. This was verified by Staff A on 09/16/13 at 2:35 PM.
Tour of the emergency department completed on 09/16/13 at 2:45 PM, revealed expired vacutainer tubes stored in the crash cart in trauma room #7. An expired sodium citrate tube dated 12/12, lithium heparin tube dated 8/13, and a sodium chloride tube dated 04/13 was observed. This was verified by Staff A on 09/16/13 at approximately 2:45 PM.
Tour of the operating room #2 completed on 09/17/13 at 9:30 AM, revealed 10 expired 24 gauge intravenous needles located in the anesthesia cart. This was verified by Staff B on 09/17/13 at 9:45 AM.

Based on observation during the life safety code tour, review of facility documentation and staff interview and verification, the facility failed to ensure it was maintained in a manner safe from fire. The facility failed to ensure: the building had a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition, that building construction type and height met the requirements for a three story building without a complete automatic sprinkler system, that corridors were separated from use areas by walls constructed with at least ? hour fire resistance rating and in non-sprinklered buildings, walls properly extend above the ceiling.

The facility also failed to ensure: that one hour fire rated construction (with ? hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas and doors were to be self-closing, that exit access to the public way was maintained, that emergency lighting of at least 1? hour duration was provided and that testing was conducted for 30 seconds per month, to ensure fire drills were held at unexpected times under varying conditions, at least quarterly on each shift, that soiled linen receptacles did not exceed 32 gal (121 L) in capacity and that a capacity of 32 gal (121 L) was not exceeded within any 64 sq ft (5.9-sq m) area and failed to ensure mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) were located in a room protected as a hazardous area when not attended.

The facility also failed to ensure: the new facility door openings in smoke barriers have at least a 20-minute fire protection rating and that doors were self-closing and rabbets, bevels or astragals were required at the meeting edges, that one hour fire rated construction with ? hour fire-rated doors in accordance with 8.4 protected hazardous areas and doors were to be self-closing or automatic closing, and the facility failed to ensure detector sensitivity was tested every alternate year thereafter the one year installation and after the second required calibration test, if sensitivity tests indicate the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. (C231) The facility failed to ensure a clean environment in the off-site physical and occupational therapy department which could affect any patient who receives therapy at the site. C(225) The cumulative effect of these systemic practices resulted in the inability to ensure the facility was maintained in a safe manner.

Findings include:

Please refer to C225 and C231 for further detail.

Based on observation and staff interview, the facility failed to ensure a clean environment in the off-site physical and occupational therapy department which could affect any patient who receives therapy at the site. The outpatient therapy off-site facility has 14 patients receiving therapy as of 9/19/13.

Findings include:

1. Tour of the off-site rehabilitation facility with Staff D on 09/18/13 revealed the following:

The hot paraffin bath had a brown substance layered on top of paraffin in the container. Staff D confirmed these findings on 9/18/13 at 11:00 AM.

Interview of Staff D at that time revealed after patient use the surfaces of patient equipment was cleaned with an antiseptic solution and a wipe. There were three cloth chairs present in the treatment room that had non-cleanable surfaces. These findings were confirmed by Staff D on 9/18/13 at 11:00 AM.

Based on facility observation, review of facility documentation and staff interview and verification during the life safety code survey it was determined the facility was not maintained in a manner safe from fire. This had the potential to affect all patients, visitors and staff members. The facility had a census of eight patients at the time of the survey.

Findings included:

The facility failed to ensure if the building had a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition. (K11)

The facility failed to ensure that building construction type and height met the requirements for a three story building without a complete automatic sprinkler system. (K12)

The facility failed to ensure that corridors were separated from use areas by walls constructed with at least ? hour fire resistance rating. In non-sprinklered buildings, walls properly extend above the ceiling. (K17)

The facility failed to ensure that door openings in smoke barriers have at least a 20-minute fire protection rating and that doors were self-closing and rabbets, bevels or astragals were required at the meeting edges. (K27)

The facility failed to ensure that one hour fire rated construction (with ? hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. Doors were to be self-closing (K29)

The facility failed to ensure that exit access to the public way was maintained. (K36)

The facility failed to ensure that emergency lighting of at least 1? hour duration was provided and that testing was conducted for 30 seconds per month. (K46)

The facility failed to ensure that fire drills were held at unexpected times under varying conditions, at least quarterly on each shift. (K50)

The facility failed to ensure that soiled linen receptacles did not exceed 32 gal (121 L) in capacity and that a capacity of 32 gal (121 L) was not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) were to be located in a room protected as a hazardous area when not attended. (K75)

The facility failed to ensure that detector sensitivity was tested every alternate year thereafter the one year installation After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. (K130)

Please see the Life Safety Code report for more specific detail.

Based on policy review and interview, the facility failed to ensure the emergency department had policies approved for patient care. This had the potential to affect every patient who receives treatment in the emergency department. The active emergency department census at the time of the survey was four patients.

Findings include:

The emergency department policies were reviewed on 09/20/13. The policy titled Emergency Services Department Patient Record and Log lacked an effective date, a review date or evidence of approval by the governing body. The policy titled Safety in the Emergency Department lacked an effective date or revision date. The policy had a signature of approval by the nurse manager of the emergency department. The policy contained hand written procedures added after the initial policy was typed and did not have an effective date of the added information.

On 09/20/13 at 2:00 PM, Staff L was interviewed. Staff L stated not all of the facility's policies had gone to the governing body for approval yet. Staff L reported some policies are awaiting approval until the facility administrative staff has a meeting. Staff L stated there is no evidence of approval of the emergency department policies or annual review of the policies.

On 09/20/13 at 2:44 PM, the facility bylaws were reviewed. The bylaws stated the facility was to conduct an annual review of procedures.

Based on interview, medical record review and policy review, the facility failed to ensure medications were administered safely in regard to known allergies and failed to ensure appropriate handwashing prior to patient contact per policy (C271). The facility failed to ensure repackaged food products are identified and dated and expired food products are removed from the refrigerator (C279). The cumulative effect of these systemic practices resulted in the facility's inability to ensure the patients' received safe care.

Findings include:

Refer to C271, C279.

Based on interview, medical record review and policy review, the facility failed to ensure medications were administered safely in regard to known allergies for one patient (Patient #28) of 33 medical records reviewed. The facility's active emergency department census at the time of the survey was four patients. This had the potential to affect all patients who receive medications in the facility's emergency department. The facility failed to ensure staff cleansed hands between contact with inanimate objects and patient contact. This affected one (Patient #14) of three patients observed for medication administration.

Findings include:

1. The medical record review for Patient #28 was completed on 09/20/13. The patient received treatment in the facility's emergency department on 06/14/13. The medical record revealed documentation the patient had an allergy to Cipro (an antibiotic), however, the patient received one dose of Cipro orally in the emergency department on 06/14/13 and received a prescription for additional nine doses of Cipro at discharge.


On 09/19/13 at 9:05 AM, Staff I, ED physician, was interviewed. The physician reported he/she was not aware of the patient's allergy to Cipro. He/she stated sometimes patient's allergies are not true allergies but merely side effects. He/she reported he/she wished there was a method in place to be able to identify true allergies from side effects. Staff I stated he/she had not been notified of the patient's Cipro reaction.

On 09/19/13 at 1:52 PM, Staff J, registered nurse, was interviewed. Staff J stated he/she was not aware of the patient's Cipro allergy. Staff J reported he/she would not have administered the Cipro to the patient had he/she knew the patient had an allergy to the medication. Staff J was unable to recall if Patient #28 was wearing an allergy wristband on 06/14/13.

On 09/20/13 at 2:07 PM, the facility's Medication Administration Competency Assessment form was reviewed. The form stated nurses are to be knowledgeable regarding each medication to be administered including side effects and contraindications.

On 09/20/13 at 2:08 PM, the facility's Safety in the Emergency Services Department (ESD) policy was reviewed. The policy stated allergies are to be noted on the ESD record, ESD nursing record, and the medication reconciliation record. The policy stated allergy bracelets are to be placed on every patient.

On 09/20/13 at 2:44 PM, the facility's Medication Error policy was reviewed. The policy stated medication given to a patient who stated he/she has an allergy to the medication is considered a medication error. The policy also stated the practitioner who ordered the drug will be notified.

A report from the patient's case worker was reviewed on 09/19/13 at 1:30 PM. The report stated the case worker had informed the facility of the patient's severe allergy to Cipro while in the emergency department with the patient on 06/14/13. The physician reported to the case worker he was aware of the patient's allergies.

Review of discharge summaries from 2010 and 2011 revealed the patient was allergic to Cipro. In 2011, the patient received intravenous Cipro at the facility for which the patient had to be transferred to a burn unit after a reaction to the Cipro.

Review of a copy of an the patient's emergency department visit from a different facility was reviewed on 09/19/13 at 1:30 PM. The record revealed the patient required treatment on 06/15/13 following a reaction to the 06/14/13 Cipro administration. The report stated the patient was evaluated for a rash to both legs. The emergency department #2 discontinued the Cipro and started the patient on a different antibiotic.




2. Observation of medication administration for Patient #14 was completed on 09/18/13 at 8:45 AM. The nurse was observed going directly to the Patient #14's room after touching the PIXIS machine (computerized dispensing system) and pulling a 500 mg bag of Flagyl (an antifungal). After hanging the medication and starting the patient's infusion pump, the nurse left the patient's room and washed his/her hands at a sink near the nurse's station, no other hand washing was observed.

Review of the policy/procedure titled Hand Hygiene and Hand Antisepsis was completed on 09/18/13 at 1:30 PM. The policy stated staff will wash hands with soap and water or alcohol hand rinse after contact with inanimate sources likely to be contaminated.

Based on observation and staff interview, the facility failed to ensure repackaged food products are identified and dated and expired food products are removed from the refrigerator. The facility's active census was eight patients.

Findings include:

During a tour of the kitchen with Staff E on 09/16/13 at 1:30 P.M., two unlabeled packages of food products were in the freezer. Staff E identified one of the food products as muffins. Staff E indicated these packages should have been labeled and dated.

With Staff E present, the food products in the refrigerator were observed. There were two individual containers of honey thickened orange juice with the expiration date of 07/23/13 in the refrigerator. The buttermilk in the refrigerator had expired on 09/12/13. Staff E indicated these products should have been removed from the refrigerator.

Based on medical record review, policy review and staff verification, staff failed to give medication as per the physician's signed order for two (Patient #12 and #18) of 33 medical records reviewed. The facility's active census was eight patients.
Findings include:
1. Medical record review for Patient #12 completed on 09/18/13 at approximately 10:30 AM revealed an order for Claritin (allergy) 10 mg by mouth daily dated 09/15/13 at 1:56 AM and to start at 6:59 AM. Further review revealed a dose was pulled and given on 09/15/13 at 6:36 AM and again on 09/15/13 at 8:20 AM. Nursing documentation revealed the second dose was overridden by the nurse at 8:20 AM. This was verified by Staff C on 09/18/13 at 10:40 AM.
Review of the policy titled Medication Administration: General Instructions completed on 09/18/13 at 3:35 PM revealed all medications, including placebos, are given only by a physician's order.
2. Patient #18 was admitted to the hospital on 09/04/13. On 09/17/13, the medical record was reviewed. A review of the physician's orders revealed medication orders for Patient #18 for Prilosec (reduce acid) 20 milligrams (mg) daily before meals and Glucosamine (assist joints) 500 mg three times per day before meals. A review of the Medication Record revealed no documentation these medications were given on 09/10/13 for the scheduled 6:00 A.M. dose.
On 09/17/13 at 3:00 P.M., Staff C confirmed these medications were not documented. Staff C was unable to provide evidence these medications were given or a reason the medications were not given.